Ob-Gyn Coding Alert

Billing for starred CPT surgical codes is subject to a set of rules different from non-starred codes. Knowing these rules as they apply to ob/gyn procedures can save coders headaches and costly claims denials. For the purpose of illustration, endometrial biopsy is used as the coding example, with the central question being whether a practice can bill for a starred procedure and an evaluation and management (E/M) office visit at the same time.

An endometrial biopsy (58100*) is a starred surgical procedure. According to CPT 2000, When a star (*) follows a surgical procedure code number, the following rules apply:

1. The service as listed includes the surgical procedure only. Associated pre- and postoperative services are not included in the service as listed.

2. Preoperative services are considered as one of the following:
When the starred (*) procedure is carried out at the time of an initial visit (new patient) and this procedure constitutes the major service at that visit, procedure number 99025 is listed in lieu of the usual initial visit as an additional service.
When the starred (*) procedure is carried out at the time of an initial or established patient visit involving significant identifiable services, the appropriate visit is listed with the modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)appended in addition to the starred (*) procedure and its follow-up care.
When the starred (*) procedure requires hospitalization, an appropriate hospital visit is listed in addition to the starred (*) procedure and its follow-up care.

3. All postoperative care is added on a service-by-service basis.
4. Complications are added on a service-by-service basis.

Cynthia DeVries, RN, BSN, CPC, coordinator of coding and reimbursement for Lee Physician Group, a 140-physician multispecialty group practice that includes 25 ob/gyn providers in Fort Myers, Fla., helps place these rules in a real-life scenario.

Scenario: An established patient presents to her gynecologist with postmenopausal bleeding. The physician takes an appropriate history and examines the patient. The doctor then makes a medical decision to perform an endometrial biopsy at that visit to rule out uterine cancer.

Coding: In this case, you would bill both an office visit for the preoperative evaluation (99212-99215, office or other outpatient visit for the evaluation and management of an established patient), depending on what the physician documented, and the procedure (58100, endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]), appending the -25 modifier to the office visit.

What CPT doesnt tell you, says DeVries, is the key to getting paid for both services is the use of two different diagnoses. In the real world, if you dont use two different diagnoses, most carriers wont pay for both services. DeVries says that in the event your physician has documented symptom(s) in the patients medical record in addition to the bleeding, you should link a symptom other than postmenopausal bleeding with the office visit and then link postmenopausal bleeding (627.1 [or 627.4 for induced menopause]) to the 58100 procedure.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., explains that as a result of what many insurers perceived as abuse of the -25 modifier, the requirement for two different diagnoses when billing for two different services was instituted a few years ago by several major carriers. If your patient has two different problems, says Callaway-Stradley, billing for starred procedures is a lot easier. But she notes that physicians or coders should never feel compelled to tweak the codes for the sake of reimbursement. Doing so may get the claim paid, says Callaway-Stradley, but it wont hold up under an audit.

Intent of Visit Must Be Clear in Notes

Billing for both the 58100 and 992XX-25 is a legitimate way to get your claim paid and should hold up with most commercial carriers, especially if your notes demonstrate the proper components for the E/M visit (history, examination and medical decision-making) that led to the endometrial biopsy. The distinction for billing the E/M visit as well as the biopsy occurs in the original intent of the office visit. If the patient already was scheduled for an endometrial biopsy when she walked through the office doors, the practice cannot bill for the office visit as well.

But if she appears with the complaint, and the physician decides during the course of the E/M visit to conduct the biopsy, then billing for both the 58100 and 992XX is justified, says Callaway-Stradley. The general idea with the use of starred procedures and the concept of modifier -25 is that you use them together if this encounter is the first time you have evaluated the present problem, and the procedure is diagnostic. If you have met the requirements of the -25 modifier, your note would stand up in an audit, providing your physician wrote a decent note.

Medicares Methods Diverge From CPT

For Medicare patients, disregard everything about billing in accordance with CPTs rules. Although its not quite that bad, Medicare does not recognize CPTs starred procedures and payment rules at all. Instead, Medicare has its own policy that affects the concept of pre- and postoperative care for surgical procedures. Many commercial carriers will not pay in accordance with CPTs rules but adhere more closely to Medicares more limited policy on the same surgeries.

For starred procedures, CPT allows for all pre- and postoperative care to be billed separately, but Medicare has a 0- or 10-day follow-up period for the same surgeries and no pre-op allowance. The exception is that if the E/M service constituted the decision to do surgery on the day of or the day before a minor surgery (as defined by Medicare), use modifier -25 to make this statement. (For Medicare, modifier -57 [decision for surgery] would be used only with visits the day of or the day before major surgery during which the decision to do surgery was made.)

Editors note: The codes in question are starred only in the CPT manual to let the coder know that special CPT rules apply the star is dropped when they are recorded on the bill.

Bear in mind that even with CPTs more liberal rules, coders still have to show a significant level of work other than the endometrial biopsy to justify billing for the office visit at the same session. Remember, even by CPTs rules, when the starred procedure is carried out and constitutes the major service in that session, practices should bill for code 99025 (initial [new patient] when starred [*] surgical procedure constitutes major service at that visit) and not the E/M visit, says Callaway-Stradley. In her experience, CPT 99025 pays about $15 to $18 for practice expense, which includes preoperative expenses. Despite CPTs guidelines, some practices report that 99025 is not paid by carriers in their state and advise coders to check with their individual carriers.

Scheduling E/M Visit and Procedure on Different Days

The ideal coding situation occurs when the physician sees the patient to evaluate the post-menopausal bleeding and schedules the procedure for another day. In this instance, you would bill the office visit for the evaluation, and when the patient returns, bill the procedure. You could then use post-menopausal bleeding for both the office visit and the procedure, and you would not have to append modifier -25, says DeVries.

As with the two diagnoses, however, practices need to demonstrate good cause for completing the E/M service and the endometrial biopsy on different days. Callaway-Stradley explains that it is very likely that both would occur on the same day, particularly if the patient has never had the complaint of post-menopausal bleeding before, or there is a risk of something else being wrong with her. If you have a scheduling issue and the patient has to come back, says Callaway-Stradley, thats one thing. They come back, and you bill for 58100 but not for an office visit. But most of the doctors I work with would rather do as much as they can at the time of the initial complaint visit rather than have the patient come back.

Although DeVries agrees that it is most convenient for the patient when both the E/M visit and the procedure can be done on the same day, she says it is rare in her experience. In our offices, the physicians are heavily booked, and to perform an unscheduled procedure would really place the physician behind schedule, she explains.

The bottom line is that practices should not have a policy of always rescheduling the patient for the starred procedure. Most commercial carriers will pay you if you submit the right information. But if they wont, they wont, says Callaway-Stradley. Rescheduling will not help, and it will be a red flag for auditors as well.